Child Health ALERT

Volume 14 A Survey of Current Developments Affecting Child Health Care January 1996

Are Head Lice Becoming Resistant To Treatment?

January is a time for "new beginnings", with children returning to school -and child-care centers after extended time at home and after visiting with relatives and friends. While children may bring some welcome new enthusiasm back to school, they may also bring something less welcome--head lice. For this reason, January is a good time to consider how to deal more effectively with this recurring problem. It's also a good time to revisit this issue because of new concerns that head lice may be developing resistance to some of the treatments that have been successfully used in the past.

General Approach

Management of head lice infestations can be greatly improved by anticipating outbreaks before they occur and by having a planned approach to preventing and dealing with them. The National Pediculosis Association (NPA) suggests that professionals responsible for the care of children establish policies for dealing with this problem (and communicate those policies to parents in advance). These should include such things as teaching screening procedures and emphasizing prevention.

Efforts should also be made to reduce the chance of spreading lice; some easy and effective things to do are to make sure that coats are not hung closely together, that hats are tucked into coat sleeves, and that children don't share clothing or head gear.

Resistant Lice

Just as some bacteria are becoming resistant to many of the antibiotics we commonly use, there also appears to be a growing problem of head lice becoming resistant to some of the agents (called pediculocides' that have been the mainstays of managing outbreaks. At this time, it is hard to know how widespread the problem is, but management approaches should take into account this possibility.

When a child needs to be treated for head lice with a pediculocide, parents should be sure to accurately follow the instructions that come with the product. It is important to understand that following these instructions is critical if the treatment is to be effective. However, because some lice may be resistant to one or another pediculocide, following the instructions may not guarantee that the treatment will work.

Unfortunately, if treatment doesn't work it may not be easy to determine whether it failed because instructions were not accurately followed or because the infestation is caused by resistant lice. The possibility that lice are resistant becomes more likely if treatment fails for a group of children from the same school or child-care center. Because the problem of resistant head lice is so new, there is confusion about how to manage children who have failed treatment.

For general guidelines, the NPA has for some time offered a brochure entitled "You Ought to Have Your Head Examined"; more recently, the NPA has also developed guidelines for managing cases of head lice that may be resistant to treatment. Interested readers can obtain, at no cost, single copies of both publications by sending a stamped, self-addressed business size envelope to the NPA at P.O. Box 610189, Newton Highlands, MA 02461; telephone (617) 449-6487 anytime for recorded messages or send $1 to the above address for a resource catalog; to report treatment failures and other problems, call (800) 446-4NPA.

CHILD CARE ISSUES

An Interview with Mary Ucci:
What Can You Do To Prepare for Outdoor Activities In Winter?

[Ed. Note: Some time ago, we interviewed Mary Ucci, Educational Director of the Child Study Center of Wellesley College, about guidelines on how winter affects the outdoor environment of the child-care center. Based on enthusiastic response to that report, and because of the cold weather that's hit most of the country early this season, we thought readers would welcome an updated interview on this important subject.

Winter weather conditions vary in different parts of the country, and while some of our readers may not experience ice and snow, and some might not even experience freezing temperatures, we think that much of what follows applies to outdoor safety in any climate.]

Q: Are there any special issues we should think about when it comes to getting children dressed to go out in the winter?

A: While it's obvious to adults that children need to dress warmly before going out, children don't easily make the connection that they are going from a warm environment to a cold one, and they therefore don't usually enjoy seasonal changes in clothing. In addition, it takes longer for them to get dressed and, more importantly, putting on winter clothes often requires greater skills at self-help tasks like fastening buttons and zipping zippers.

Though it's more complicated dressing children for outdoor activities in winter, adults who have supervisory responsibilities should be careful to not communicate to the children the additional effort this daily routine involves. Children have a natural enthusiasm for playing outdoors, and we should support this enthusiasm in all seasons, including winter (in all but the most severe weather).

Q: What problems or issues does the outdoor environment pose in winter?

A: There are really two-components to the outdoor environment-structures, such as playground equipment and fences, and the elements, such as ice and snow. With respect to the structures, fence gates can freeze, making them difficult to open and close. The biggest problems, however, come from metal playground equipment and fencing in freezing weather, since these objects "invite" children to put their tongues and lips on them, risking the very real possibility that they will freeze on the metal. While more and more equipment is being made from or covered with plastic (especially plastic-coated fencing), it is important that a staff member be in attendance to pay particular attention to this hazard.

In terms of natural elements, ice and snow become part of the playground environment. When snow is deep and crusty, children walking on top of it can reach heights that are otherwise unreachable--for example, they can reach the top of fences. In addition, high and crusty snow can pose a serious hazard for young children who may fall through the crust and not be able to maneuver themselves to safety. Ice, obviously, is slippery, and icicles can be dangerous when used as toys.

Q: Doesn't the bulky clothing protect children from many of these hazards?

A: In some ways, it does. However, it's important to remember that bulky clothing impairs a child's ability to maneuver, boots are clumsier and often have less traction than sneakers, and mittens or gloved hands can't grasp as well as uncovered hands. In addition, nylon snowsuits have so little friction that children can go surprisingly fast on slides and down snowy hills. These changes can allow children to move in ways they didn't anticipate, and their judgement can therefore be inaccurate.

Q: What should parents know about the kinds of outdoor clothing their children need?

A: Parents clearly know that their children need warm clothing, but they should also be made aware of other issues for example, it's best if the clothing comes in layers, and that mittens, gloves, and boots have good gripping surfaces.

In addition, new types of clothing have become available for children, and many items offer real advantages. For example, special materials can make coats, hats, and mittens both warm and lightweight, and items should be selected so that they are comfortable and allow the child the widest range of movement.

Q: What about adult supervision in the playground?

A: We tend to think of supervision as something you do while the children are in your care, but we often neglect to recognize that there is another aspect to supervision--the staff needs to consider potential problems before they occur and formulate rules and procedures in advance. The staff needs to know if certain activities should be discouraged or prohibited-for example, can the children use shovels (preferably plastic) and if so, should they always be kept close to the ground? Can children eat snow? Can they throw it?

Just because children are outside doesn't mean they should be free from all rules. Outdoor time is not "recess", rather, it should be a time for additional enrichment.

Q: Any final thoughts?

A: We shouldn't forget that winter playgrounds can present wonderful new environments for children. There are opportunities to observe and-collect leaves and pinecones, to make footprints, and to build things out of snow. Children can be directed to appropriate experiences if they are dressed and supervised properly.

(Mary Ucci is an advocate for developmental approaches to preschool teaching and a specialist in establishing developmentally-appropriate environments for young children. Her comments have appeared frequently in CHILD HEALTH ALERT, and she is a member of the CHILD HEALTH ALERT Editorial Advisory Board)

RESOURCES

Drawstrings In Children's Jackets And Sweatshirts

In the last 10 years, the U.S. Consumer Product Safety Commission (CPSC) received reports of 17 deaths and 42 non-fatal accidents involving children whose hood and waist drawstrings became entangled on playground equipment, bus doors, and other common items. These tragedies prompted the CPSC to develop guidelines that helped clothing manufacturers design products without drawstrings In the the neck and hoods of children's outerwear. The guidelines also tell parents to take drawstrings off the hoods and necks of children's jackets and sweatshirts, and to substantially shorten the drawstrings around the bottom on coats and jackets.

Child-care providers, health care professionals, and parents can obtain a copy of "Guidelines for Drawstrings on Children's Clothing" by sending a postcard with their name and address to "Drawstring Guidelines," CPSC, Washington, D.C. 20207. This is a good resource for your bookshelf and to put on bulletin boards.

MEDICATION

Are Too Many Children Treated With Ritalin?

In just one week last month, two network TV newsmagazine shows made a similar point: there is a growing and perhaps inappropriate use of Ritalin (a brand of the medication methylphenidate) for the treatment of attention deficit-hyperactivity disorder (ADHD). Both reports acknowledged that children with ADHD can benefit greatly from treatment with Ritalin; however, they also questioned whether the medication was being used too frequently, particularly in children who were disruptive in class but might not have ADHD.

COMMENT. These last weeks have been difficult for parents of children who are taking Ritalin! Last month, there were concerns about Ritalin being abused by college students for its stimulant effects (CHILD HEALTH ALER T, December, 1995), and we worried that appropriately -treated children might feel they are taking an illicit drug. The concern this time focus not on abuse of Ritalin by young adults, but inappropriate use of Ritalin among children who don't clearly need the medication.

We've frequently criticized the way TV reports tend to sensationalize child health issues, but these reports made some very important points. First, they supported the fact that ADHD is a real condition that very often responds dramatically to Ritalin and similar medications. Second, they argued (correctly, we think) that there are times when a child who is disruptive in class may be treated with Ritalin even though that child doesn't have ADHD. This may happen because the diagnosis of ADHD is not always clear cut; also, parents of disruptive children--and the teachers who must cope with those children--may pressure health care providers to "do something".

Children with ADHD should not be denied the benefits of Ritalin, and children should not be placed on Ritalin unless there is a clear medical reason to do so. To help keep this balance, the diagnosis of ADHD is best made by practitioners who are skilled in both the diagnosis and management of this condition. With this approach, parents whose children are on Ritalin can be reassured that their child was appropriately evaluated and diagnosed.

PRODUCT RECALLS

Recalls: Munchkin Pacifiers...

Munchkin, Inc. is recalling almost 200,000 assorted styles of glitter pacifiers because they may separate into pieces and could pose a choking hazard to young children. The pacifiers measure 2.25 inches long and 1.5 inches wide, and were sold in four styles, each of which has a disk filled with liquid and glitter.

The "Hello Kitty" has a picture of a white cat in the disk; the "Keroppi" has a picture of a frog, the "Pekkle" has a picture of a white duck, and "Crayola" has either crayons and a dinosaur in the disk or clouds and a picture of a cow in the disk,

The pacifiers were sold individually for about $2, but the "Crayola" style was also sold as part of the "Munchkin Crayola Infant Gift Set" (for about $7), which includes a bottle, squeaker toy, bib, and infant feeding spoon.

Consumers should return the pacifiers to the place of purchase for a full refund. For more information, call Munchkin, Inc., at 800 247-2223 or write the company at 8257 Woodley Ave., Van Nuys, CA 92406.

... Carbon Monoxide Detector...

Revco Products is recalling over 10,000 carbon monoxide detectors because the alarm may fail at hazardous levels of this poisonous gas. The recall involves Model 840 Gas Sniffer carbon monoxide detectors, which are rectangular, tan, plastic devices measuring 3.5 by 4 inches and 1.5 inches deep. They have horizontal and vertical vents and the words "Gas Sniffer" on the front of the detector, next to an on/off switch.

The devices were sold in the eastern U.S. from June 1986 to August 1995 as accessories with coal stoves; they were also sold separately for $74.95. Consumers should return the detector for a full refund (plus postage up to $3) to Revco Products, 5622-B Research Dr., Huntington Beach, CA 92649. For more information, call the company at 800 658-4658.

... And Modification For Teenage Mutant Ninja Turtles Chairs

Ace Novelty is instructing consumers to remove the strap on over 69,000 "Teenage Mutant Ninja" foam chairs, since children can become entangled and strangle in the strap. Each of the green plush chairs features a yellow seat and a Ninja Turtle head as a backrest; there is a red bandanna around the backrest and red mesh wrist straps on the arms.

They came in four styles, all with model #28021: "Raphael", "Leonardo", "Michelangelo", and "Donitello", and were sold nationwide from January 1990 through April 1991 for approximately $19.

Consumers should cut the bandanna-style strap from the chairs and discard the strap. For questions, call Ms. McCoy at Ace Novelty at 800 759-1223, between 8:30 AM and 5 PM, PST.

Winter Hint:

When the weather is cold, it's important to keep indoor air from becoming too stuffy. Don't set the thermometer too high--ideally, it should be set between 68' and 72' F.

Also, air out rooms by trying to keep windows open for at least 5 to 10 minutes each day.

CHILD CARE ISSUES

Children, Car Seats, And Air Bags: Guidelines For Safety

Recently, many news reports described a number of instances in which infants and children died when they were struck by air bags that inflated during car accidents. Air bags are known to have saved about 900 lives since they were introduced, so some of these reports may have been confusing because they didn't clearly point out the circumstances where air bags could actually be dangerous.

Children can be harmed by air bags in two different situations. First, if an infant or child is not restrained in the front seat and there is an accident, the child can be thrown into the air bag as it is inflating, causing serious injury. Second, if an infant is in a rear facing car seat that is placed on the front seat, even if the infant seat is properly secured, the air bag can hit the part of the car seat closest to the dashboard and cause serious injury to the child.

To prevent these injuries and deaths, the U.S. National Highway Traffic Safety Administration (NHTSA) is conducting an important educational campaign that hopes to reach all parents of infants and young children and all child-care professionals. The messages include three simple points:

1. Never put a rear-facing infant seat in the front seat of a car with a passenger-side airbag.

2. Make sure all children are buckled up, no matter where they sit in the car.

3. The rear seat is the safest place for children of any age to ride.

As part of this campaign, NHTSA is making available, at no cost, a packet of educational materials that includes a colorful poster, reproducible handouts, and news releases. Some of the information is also available in Spanish. Requests can be made by fax to (202) 493-2062, or by writing NHTSA, 400 Seventh St., SW, Washington, DC, 20590.17